About Reactive Arthritis

From the nation’s leading law firm representing victims of campylobacter and other foodborne illness outbreaks.

Chapter 2

What are the Symptoms of Reactive Arthritis?

The most common symptoms of reactive arthritis are arthritis, conjunctivitis, and urethritis.

The three most common symptoms of reactive arthritis are arthritis, conjunctivitis, and urethritis. The onset of symptoms typically occurs one to four weeks following the initial infection and may present acutely or develop slowly over time. It can occasionally occur years after the initial infection.

In many patients, urethritis and conjunctivitis symptoms are mild, symmetric, and bilateral. [11, 12] Bacterial cultures are negative and the inflammation typically resolves within 10 days without treatment.

Urethritis, a urinary tract inflammation, is often accompanied by symptoms such as a penile discharge in males, pain with urination, or blood in the urine. Females may also present with an inflammation of the cervix or pain during intercourse. Urethritis in either males or females may also be present without symptoms but can show up on a urine test with your doctor. [8]

Ophthalmic, or eye, manifestations occur in approximately one-third of individuals with Salmonella-associated arthritis. [8] The involvement of the eye in reactive arthritis is most commonly manifested as conjunctivitis, an inflammation of the mucous membrane that covers the eyeball. Conjunctivitis usually appears within a few weeks of the onset of arthritis. Conjunctivitis and uveitis often presents with redness of the eyes, eye pain and irritation, blurred vision and a yellowish discharge. Conjunctivitis is present in up to 50% of affected individuals and can develop at any time during the course of the disease, although it is more common in reactive arthritis associated with genitourinary or Shigella infections. [13]

Anterior uveitis, an inflammation of the inner eye, is the second most common ocular symptom of Reiter’s syndrome, occurring in up to 12% of affected persons. [12] Uveitis is most often acute, unilateral, and recurrent. [14, 15] It is more frequent in those who are HLA-B27 positive and in individuals with sacroiliitis, an inflammation of the sacroiliac (sacrum and ilium) joint or region. [13] Other ocular conditions also have been associated with Reiter’s, including scleritis, cataract, glaucoma, keratitis, papillitis, retinal and disc edema, and retinal vasculitis. [16]

The arthritis associated with Reiter’s syndrome generally occurs rapidly, with joints becoming hot and swollen; large effusions, or collections of fluid, can develop in the knee joint or ankle. [1, 8] Wrists, fingers and other joints can be affected, although with less frequency. Joint pain without inflammation may also occur at sites other than those affected by inflammation. A condition called enthesopathy also commonly occurs, in which the tendon that attaches to the bone becomes inflamed. [8, 13] Enthesopathies occur in 5 to 21% of individuals with Salmonella-associated arthritis. [8] The heel is the most common site with the development of heel pain and Achilles tendonitis, but pain at the insertion of the patellar (kneecap) tendon into the tibia, the larger of the two bones in the lower leg, may also occur. Some individuals with reactive arthritis may develop heel spurs, bony growths that cause chronic foot pain. Arthritis from reactive arthritis can also affect the joints of the back, causing spondylitis, an inflammation of the vertebrae and the attached disks and ligaments in the spinal column, and asymmetric sacroiliitis. [15] Patients will present with pain and morning stiffness in the lower back or neck. Pain will be worse after rest or sleep and better after walking for a while.

The duration of reactive arthritis symptoms can vary greatly. The literature suggests that the majority of affected individuals recover within a year although reactive arthritis can become chronic. [13, 17] Up to 50% of those with reactive arthritis may have recurrent bouts of arthritis and 15 to 30% develop chronic arthritis or sacroiliitis. [15] In one study, 18 (67%) of 27 individuals who developed reactive arthritis after a Salmonella infection continued to have symptoms at five years of follow-up. [17] Symptoms were severe enough to force a change in work for four individuals and another four had objective damage to joints radiographically.

Other symptoms of reactive arthritis may include a painless skin rash on the penis in men called circinate balanitis. Skin rashes on the soles of the feet and, less often, on the palms of the hands or elsewhere may also occur; these rashes are called keratoderma blennorrhagicum (or keratosis blennorrhagica) and are similar to psoriasis. They often begin as clear vesicles (blisters) on a red base and progress to macules (flat lesions), papules (raised lesions), and nodules (firm bumps). [13] In addition, some people develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed.